Prosthetic Options in Implant Dentistry chapter 5 Presented by:Dr.Samaneh Abbasi Supervised by: Dr. Mansour Rismanchian And Dr.saied Nosouhian Dental of implantology Dental implants research center Isfahan university of mediacal science  

Implant dentistry begins with a diagnosis of the patient's condition The dentist cannot add natural abutments, but in implant dentistry can provide a range of additional abutment locations determining final prosthodontic treatment plan before implant insertion

Completely edentulous prosthesis design Cost is the primary factor Ask about the patient's desires Fixed or removable The existing anatomy is evaluated after it has been determined whether a fixed or removable

But Too often, for completely edentulous patients: Maxillary denture and a mandibular overdenture with two implants But In the long term, may prove a disservice to the patient Maxillary arch will continue to lose bone The bone loss may even be accelerated in the premaxilla Reduced posterior occlusion on the maxillary Posterior bone loss to continue in the mandible Paresthesia Facial changes

It is even more important to visualize the final restoration at the onset with a fixed-implant restoration Patients feel the implant teeth are better than their own The completely implant-supported overdenture requires the same number of implants as a fixed implant restoration Thus the cost of implant surgery may be similar Fixed prostheses often last longer than overdentures Food entrapment under a removable overdenture is often greater Soft tissue extensions and support are often required in the removable Chair time and laboratory fees are often similar for fixed or removable restorations that are completely implant supported

PARTIALLY EDENTULOUS PROSTHESIS DESIGN

joining implants to teeth More implants Cost

ln 1989, Misch proposed five prosthetic options for implant dentistry:

FP-1 Replace only the anatomical crowns Minimal loss of hard and soft tissues The volume and position of the residual bone must permit ideal placement of the implant in a location similar to the root of a natural tooth Very similar in size and contour to most traditional fixed prostheses Most often desired in the maxillary anterior region

The implant abutment can rarely be treated exactly as a natural tooth: 1. The placement of the implant rarely corresponds exactly to the crown-root position of the original 2. The thin labial bone lying over the facial aspect of a maxillary anterior root remodels 3. The occlusal table is also usually modified in Unesthetic regions 4. Bone augmentation is often required 5. Soft tissue augmentation also is often required to improve the interproximal gingival contour "Black" triangular spaces 6. Difficult to achieve when more than two adjacent teeth are missing

Material The restorative material of choice for an FP-1 prosthesis is porcelain to noble-metal alloy Easily be separated and soldered in case of a nonpassive fit at the metal try-in Noble metals in contact with implants corrode less than nonprecious alloys Any history of exudate around a subgingival basemetal margin will dramatically increase the corrosion effect between the implant and the base metal

FP-2 Restore the anatomical crown and a portion of the root The volume and topography of the available bone is more apical (1 to 2 mm below the cement-enameljunction) Incisal edge is in the correct position, but the gingival third of the crown is overextended Are similar to teeth exhibiting periodontal bone loss and gingival recession

The patient and the clinician should be aware from the onset of treatment that the final prosthetic teeth will appear longer than healthy natural teeth without bone loss How???

Esthetic zone The esthetic zone of a patient is established during : 1.Smiling in the maxillary arch high lip line during smiling 2.Speech of sibilant sounds for the mandibular arch Low lip line during speech

A multiple-unit FP-2 restoration does not require as specific an implant position in the mesial or distal position because the cervical contour is not displayed during function The implant position may be chosen in relation to bone width, angulation, or hygienic considerations rather than purely esthetic demands (as compared with the fp-l prosthesis) The implant may even be placed in an embrasure between two teeth that often occurs for mandibular anterior teeth for full-arch fixed restorations It should be placed in the correct facial-lingual position to ensure that contour, hygiene, and direction of forces are not compromised

Material The material of choice for an FP-2 prosthesis is precious metal to porcelain

FP-3 replace the natural teeth crowns and has pink-colored restorative materials to replace a portion of the soft tissue original available bone height has decreased by natural resorption or osteoplasty at thetime of implant placement teeth are unnatural in length patient may also have greater esthetic demands Patients complain the display of longer teeth even though they must lift or move their lips in unnatural positions greater moment of force is placed on the implant cervical regions, especially during lateral forces (e.g., mandibular excursions or with cantilevered restorations)

There are two approaches for an FP-3 prosthesis: a hybrid restoration of denture teeth and acrylic and metal substructure a porcelain-metal restoration The primary factor that determines the restoration material is the amount of crown height space Occlusal vertical <15mm ≥15mm PORCElAIN –METAL HYBRID

Excessive CH & traditional porcelain-metal restoration ??? Porcelain thickness will not be greater than 2-mm thick More shrinkage Non-Precious metals porosities in the structure lead to fracture large amount of metal increases the risk of porcelain fracture Precious metals weight and cost

REPAIR of the restoration is more commonly needed Hybrid restoration Smaller metal framework Denture teeth and acrylic Less expensive to fabricate Highly esthetic Acrylic pink soft tissue replacements The impact force of dynamic occlusal loads is reduced Easier to repair The fatigue of acrylic is greater than the traditional prosthesis REPAIR of the restoration is more commonly needed

Food impaction or speech problems Wide open embrasures in the maxillary arch 1. Using a removable soft tissue replacement device 2. Making overcontoured cervical restorations The maxillary fp-2 or the fp-3 prosthesis is often extended or juxtaposed to the maxillary soft tissue so that speech is not impaired. Hygiene is more difficult to control, although access next to each implant abutment is provided

Removable Prostheses

Removable Prostheses 1. RP-4 2. RP-5 Two kinds of removable prostheses, based upon support of the restoration: 1. RP-4 2. RP-5 determined by the amount of implant support The difference in the two categories of removable restoration is not in appearance Complete removable overdentures have often been reported with predictability The removable prosthetic options are primarily overdentures for the completely edentulous patient

RP-4 The restoration is rigid when inserted Completely supported by the implants, teeth, or both The restoration is rigid when inserted A low-profile tissue bar or superstructure that splints the implant abutments 5 or 6 implants in the mandible 6 to 8 implants in the maxilla More lingual and apical implant placement in comparison with the implant position for a fixed prosthesis Same appearance as an Fp-l, FP-2, or FP-3 restoration Improved oral hygiene Sleep without the excess forces of nocturnal bruxism on the prosthesis The implants in an RP-4 prosthesis (and an FP-2 or FP-3 restoration) should be placed in the mesiodistal position for the best biomechanical and hygienic situation

RP-5 combining implant and soft tissue support The amount of implant support is variable: (1) Two anterior implants independent of each other (2) Two Splinted implants in the canine region to enhance retention (3) Three splinted implants in the premolar and central incisor areas to provide lateral stability (4) Implants splinted with a cantilevered bar to reduce soft tissue abrasions and to limit the amount of soft tissue coverage needed for prosthesis support The primary advantage of an RP-5 restoration is the reduced cost The clinician and the patient should realize that the bone will continue to resorb in the soft tissue-borne regions Relines and occlusal adjustments every few years Bone resorption with RP-5 restorations may occur two to three times faster than the resorption found with full dentures

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